improving effectiveness and efficiency in office based

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N j H T l MD FACP

Improving Effectiveness and Efficiency in Office

Based Practice


Based Practice

Neeraj H. Tayal, MD, FACPAssistant Professor of Clinical Medicine

Division of General Internal Medicine and GeriatricsDepartment of Internal Medicine

The Ohio State University Wexner Medical Center

Problems with Health CareProblems with Health Care

• Delays in care

• Disparities

• Cost is too high

Miscommunications• Miscommunications

• Poor coordination

• Burn out

“Work Smarter not Harder”

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Effectiveness – “doing the right thing”Effectiveness – “doing the right thing”

• Answering patient calls within 30 seconds

• Notifying patients of test results within 2 days

• Register and room patients within 5 min

• Respond to patient calls by day’s end

• Going home at a reasonable time

Efficiency – “Doing the thing right”Efficiency – “Doing the thing right”

• With the least amount of resource

– Materials, Space, Time, Staff

• While still maintaining quality

• Creating the opportunity to backfill with value

– Update equipment

– Extra exam rooms or workstations

– More time with patients

– More personal time

The Study of WorkThe Study of Work

• Scientific management theory

• Methods engineering

• Industrial engineering

• Systems engineering

• Increase desired outcome of a job (process)

• Make the job (process) easier

Frederick W Taylor (1880)Frederick W Taylor (1880)

Image from Wikipedia

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Frank and Lillian Gilbreth (1885)Frank and Lillian Gilbreth (1885)

Images from Wikipedia

The Study of WorkThe Study of Work

• Time Study –designed to measure how long an average worker takes to complete a task

• Motion Study – designed to determine the best way to complete a repetitive activity

Time and Motion Studies

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Brick Laying (multistep process)Brick Laying (multistep process)

• Stooping

• Lifting

• Turning

W lki

• Inconsistency

• Inaccuracy

• Wasted materials

W t d ti• Walking

• Applying mortar

• Laying brick

• Wasted time

• Work injury “burn out”

Application of Work StudyApplication of Work Study

• Manufacturing

• Banking

• Military

• Healthcare

– Ex. Scrub Nurse

Scrub NurseScrub Nurse

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DMAIC and PDSADMAIC and PDSA

• D – Define

• M – Measure

• A – Analyze

• P – Plan

• D- Do

• S – StudyA Analyze

• I – Implement

• C – Control (sustain improvement)

S – Study

• A - Act

Flow Chart the ProcessFlow Chart the Process

Data Collection for Cycle TimeData Collection for Cycle Time Cause and Effect “fishbone”Cause and Effect “fishbone”

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Target Checkout CounterTarget Checkout Counter

Response Time Delay Before& After Pilot

Response Time Delay Before& After Pilot

Where To Get Started?Where To Get Started?

• Waiting area

• Registration

• Call center

• Nurses stations• Nurses stations

• Communications

• Documents

• Electronic medical record system

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G il G MD


Based Practice


Based Practice

Gail Grever, MDAssistant Professor-Clinical

Division of General Internal Medicine and GeriatricsDepartment of Internal Medicine

The Ohio State University Wexner Medical Center

“The value of an idea lies in thelies in the using of it.”-Thomas A. Edison


Source: de.wikipedia, original upload 26. Jun 2004 by Author: KMJ, alpha masking by Edokter

Effectiveness and Efficiency


• Transformation occurs when a deliberate process is used to analyze needs and available resources.eeds a d a a ab e esou ces

• GOAL = VALUE ADDED (More time, space, staff to devote to other office needs)

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• Transformation requires vision– Looking at our resources from a different

perspective

• Resource Utilization – Space– Information/Materials– Time– Relationships (RN, MA, MD, Patients)

RESOURCE #1: SpaceRESOURCE #1: Space

Source: Cubespace Author: Asa Wilson

Space UtilizationSpace Utilization

• Goal - Use space available to improve efficiency in three areas

Clinical Area – Improve Patient Carep

Registration – Improve Patient Flow

Call Center – Improve Access

Clinical Area – Improve Patient CareClinical Area – Improve Patient Care

• Team approach to Patient Centered Medicine

• Doctors are not practicing in isolation

– Nurses

– MAs

– Pharmacists

– Social Workers

– Nutritionists

• Clinical workspace needs to reflect this philosophical change

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Clinical Area – Improve Patient CareClinical Area – Improve Patient Care

• Our clinical area had limited function

– Need:

• Any given half day: 6 MDs + 6 MAs + 1 pharmacist + 1-2 learners + RN = 16-17 workstationsworkstations

– Actual capacity:

• 4 total workstations for MDs + 3 computers at nursing station = 7 workstations

• Physical barriers led to communication barriers

Before RenovationBefore Renovation

Before RenovationBefore Renovation


After RenovationAfter Renovation

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Clinical AreaClinical Area• New design added workstations and

opened up walls12 stations (compared to 6) for providers

+ 4 computers (compared to 3) for nursing stations

Total: 16 workstations

– Increased communication between MD & MA– Better learning environment for students– Effective environment for charting

RegistrationRegistration

• Add equipment

• Improve workflow

• Decrease patient wait time

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Registration – Improve workflowRegistration – Improve workflow

• One printer and one scanner shared for 4 workstations– Waiting for available scanner/printer– Movement from desk required with each q

patient check-in• Single monitor screen

– Toggle back and forth for different aspects of registration

Registration – Improve WorkflowRegistration – Improve Workflow

• IF…

– 30 seconds saved for each patient registration

• FOUND TIME…

– 690,000 seconds per year

– 11,500 minutes per year

– 191 hours per year

– 23 days per year

Call Center – Improve AccessCall Center – Improve Access

• More staff needed to accommodate the results of the call center project

• Staffing increase from 3 to 6 call center employees

• Need to add 3 more work stations

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Call CenterCall Center Call CenterCall Center

Call Center – Improve AccessCall Center – Improve Access

• Utilizing space improved:

– Quantity of workstations

– Quality of environment

• Warm, inviting, clean

• Better staff retention

• More skilled/experienced staff over time

RESOURCE #2: InformationRESOURCE #2: Information

GOAL: Organize and Utilize

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BEFORE AFTERBEFORE AFTER Resource #3: Time Resource #3: Time

• How can we shave seconds off a process?

• Those seconds lead to hours to devote to other tasks…

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Time Utilization:Refill RequestsTime Utilization:Refill Requests

Electronic scripts helped save time but significant work devoted to refills still exists


Refill Requests

Refill Requests

Fax RequestReceived

Med Records

Personnel : Take off fax

and sort

Med Records

Personnel: Label fax with MRN

MA creates refill

encounter

MD reviews and approves

Refill Request Intervention

Refill Request Intervention

All requests pended for 90 day supply with 3 refills

(With exception of controlled substances)

• Goal: To create uniform process thatGoal: To create uniform process that decreases frequency of refill requests= TIME SAVED

• Based on article from Dr. Christine Sinsky

• Christine A. Sinsky, MD. Improving Office Practice: Working Smarter, Not Harder: Seemingly simple strategies can transform your practice. Fam Pract Manag. 2006 Nov-Dec;13(10):28-34.

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Intervention EffectsIntervention Effects• Decreased faxes for Med Records to sort = FOUND TIME

• Decreased refill requests for MA staff to enter= FOUND TIME

• Decreased items in EMR inbox for MD toDecreased items in EMR inbox for MD to review

= FOUND TIME• Decreased failed transmissions of requests

(fax machine not busy)• Decreased waiting - improved patient

satisfaction

ConcernsConcerns• Using refill requests to “catch” chronic

disease patients who miss their appointments

• Patients won’t keep their follow up • Physicians can change amount and

b f fill h th i dnumber of refills when they sign order • Decrease in MA work time for refills can

now be shifted to develop a more proactive recall system for no shows

Christine A. Sinsky, MD. Improving Office Practice: Working Smarter, Not Harder: Seemingly simple strategies can transform your practice. Fam Pract Manag. 2006 Nov-Dec;13(10):28-34.

Resource# 4: RelationshipsResource# 4: Relationships

Image from Wikipedia Commons

Relationships:Utilization and Organization

Relationships:Utilization and Organization

• Successful relationship relies on successful communication

• Communication must be easy

T k th k i• Teams can make the work even easier

• Methods

– Pre-Visit Calls

– Team Communication using EMR

– Electronic patient portal

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Relationships:Organization and Utilization

Relationships:Organization and Utilization

• Doctor to Patient

• Doctor to MA

• Nurse to MA

• Doctor to Nurse

• MA to Patient

• Nurse to Doctor

• Social worker to Patient

• Pharm to Patient

• Patient to Nurse

Pre-Visit CallsPre-Visit Calls

• RN or MA starts the visit before patient walks into clinic

• Intervention Effects:– Prioritize/Triage list of patient concerns– Prioritize/Triage list of patient concerns– Update EMR with medication changes– Identify and obtain information from

interval hospital admissions and ED visits

– Decrease No Show Rates

MD-MA-RN Communication ToolsMD-MA-RN Communication Tools• Staff Messaging within EMR


Electronic Patient PortalElectronic Patient Portal


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Electronic Patient Portals

Electronic Patient Portals

SummarySummary• Transformation requires resources

and vision

• Deliberate process leads to maximal impact of changep g

• Look at your own practice’s resources

• A change in perspective can lead to a change in efficiency and effectiveness